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4 Initial Results of the Integration Demonstration This chapter analyzes the initial results of the effort to merge the health care centers of the Navy and the Department of Veterans Affairs (VA) in North Chicago into a single integrated health care center that improves ac- cess, quality of care, and cost effectiveness; maintains military operational readiness; maintains patient and staff satisfaction; and improves research and training opportunities. Before examining data on these outcomes, however, the chapter documents the organizational results of the merger, especially the degree of integration achieved. These are initial results because the Captain James A. Lovell Federal Health Care Center (FHCC) had been in operation only for a year and a half when this report was drafted and is still a work in progress. For exam- ple, the electronic health records (EHRs) of the Lovell FHCC beneficiaries are not yet fully integrated, which means that inefficient workarounds are required to ensure patient safety, let alone deliver improved care through better coordination. In addition, the bulk of the effort to launch the Lovell FHCC was spent planning and implementing the basic administrative sys- tems necessary to operate the new organization, such as payroll, account- ing, computer access, and credentialing. The leadership of the Lovell FHCC plans to focus more attention in the next several years on opportunities to better integrate clinical services (Interviews). DEGREE OF INTEGRATION Although the term “integration” has been widely used to describe the consolidation of the North Chicago VA Medical Center (NCVAMC) and 103

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104 LOVELL FEDERAL HEALTH CARE CENTER MERGER the Naval Hospital Great Lakes (NHGL), it was never formally defined. Dictionary definitions of integration range from the process of joining enti- ties together1 to the process of blending into a functioning whole.2 These definitions could apply to very different situations, for example, the simple collocation of DoD and VA clinics in the same building that share a labo- ratory versus a more ambitious unification of like clinics that are jointly staffed and serve both Department of Defense (DoD) and VA beneficiaries. According to the Lovell FHCC’s concept of operations, the planning as- sumptions supported the more expansive concept of integration. The as- sumptions included the following: • There is total integration—a single chain of command exists with single departments. • There are unified operating systems whenever possible. • There is one standard of care. • There is a single medical staff. • There is seamless transition from active duty to veteran status. • The two organizational cultures must blend into one. • The integrated facility has flexibility to adjust staffing based upon mission requirements (Lovell FHCC, 2010a, p. 15). Although the vision of the FHCC planners was total organizational integration, including single operating systems, blended staff, and seamless care delivery regardless of beneficiary status, the implementation history in North Chicago reveals the limits to and the costs of integration, as well as some of the beneficial outcomes that might be realized from the creation of the FHCC. The limits pertain to differences between the beneficiary popula- tions in terms of health needs and eligibility; differences in the departments’ missions in North Chicago (i.e., preparing recruits for deployment versus meeting the health needs of veterans); the limited ability of the two EHR systems to interface to allow an integrated patient record; and the need to continue to meet different standards and reporting requirements of the agencies (the VA, the Navy, and the DoD). The costs pertain to the extra time it takes to meet the requirements of two reporting chains; the duplica- tion of functions that could not be unified; and the need to develop and maintain interoperability capabilities between separate systems (e.g., EHR systems, accounting systems, credentialing systems, drug formularies). The 1  “1. To make a whole by bringing all parts together; unify; 2a. To join with something else; unite; 2b. To make part of a larger unit” (American Heritage College Dictionary, 3rd ed., Boston, MA, Houghton Mifflin, 1997). 2  “To form, coordinate, or blend into a functioning or unified whole: unite” (Webster’s Ninth New Collegiate Dictionary, Springfield, MA, Merriam-Webster Inc., 1987).

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 105 benefits were expected to be increased access to care (in terms of a greater range of services for both DoD and VA beneficiaries); better quality of care (in terms of coordination and continuity of care and access to a greater range of specialties for consultation and referral); lower operating costs (because of reduced duplication of both administrative and clinical func- tions and economies of scale); greater patient and staff satisfaction; and more research and training opportunities. In this section of the chapter, the extent of integration—defined as the blending of previously separate entities into a cohesive whole—is explored. The degree of integration will be analyzed along three dimensions: (1) func- tional integration, (2) physician integration, and (3) clinical integration. • Functional integration is “the extent to which key support func- tions and activities (such as financial management, human re- sources, strategic planning, information management, marketing, and quality improvement) are coordinated across operating units so as to add the greatest overall value to the system” (Shortell et al., 2000, p. 31). • Physician integration is “the extent to which physicians and the organized delivery systems with which they are associated agree on the aims and purposes of the system and work together to achieve mutually shared objectives” (Shortell et al., 2000, p. 67). • Clinical integration is “the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients” (Shortell et al., 2000, p. 129). Functional Integration Administrative services are combined and integrated to some extent at the Lovell FHCC, although the need to adhere to the different business rules and procedures of the DoD and the VA requires a certain amount of duplication and limits the realization of optimal operating efficiencies. In addition, some services, or product lines, are provided at the regional or the national level by one department or the other. For example, human resources (HR) services for the NCVAMC were provided by the Veterans Integrated Service Network (VISN) 12. In that case, the FHCC was able to establish an integrated local HR office. In other cases, integration was not possible. For example, the DoD has a national contract to provide appoint- ment call center services at the military treatment facilities (MTFs), which means that there are separate call centers at the FHCC for DoD and VA beneficiaries. In any case, under the terms of the National Defense Authori- zation Act of 2010 (NDAA 2010), the FHCC cannot cut staff, even though

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106 LOVELL FEDERAL HEALTH CARE CENTER MERGER efficiencies from the integration might require fewer staff. In addition, the FHCC has not been under pressure initially to reduce costs because it is receiving the same funding—with inflation adjustments—that it did before the integration during the first several years of operation. In early September 2009, more than a year in advance of the launching of the FHCC, the communication staffs of the Naval Health Clinic Great Lakes (NHCGL) and the NCVAMC were functionally integrated in a single Department of Communications and Public Affairs. The department was charged with meeting Navy, VA, and Lovell FHCC communication needs and designing and implementing a single, comprehensive communication plan to address the concerns of all the stakeholders (VA, 2010a). In October 2009, education and training programs were functionally integrated in a single Department of Education and Training (Fouse and Faber, 2011). In October 2010, the remaining administrative offices were combined under the Resource Directorate (Offices of HR, Financial Management, Informa- tion Resources Management, and Information Security) and the Facility Support Directorate (Offices of Communications and Public Affairs, Man- aged Care Operations, Protective Services, Patient Administration, Facili- ties Management, and Logistics). There is a single Office of Performance Improvement in the executive office. The intent was for the operations within these offices to be integrated, that is, to have one set of policies and procedures for the entire FHCC. However, as is documented in Chapter 3, the degree to which integration is possible has been circumscribed by differ- ences in policies and procedures between the parent departments to which the FHCC must continue to adhere. For example, the departments could not agree to have one of the two inspectors general conduct inspections on behalf of both departments, so the Office of Performance Improvement must manage two inspection processes. Although there is a single HR office, there are separate units for VA and DoD personnel. Physician Integration The clinical task group recommended from the start that Navy active duty and VA physicians be unified through the development of a single set of medical staff bylaws and organization into single departments under a single chief medical executive. It became evident, however, that it made sense to create a separate organization for dental services because of the volume of dental work and the size of the dental staff, which also conforms to the Navy practice of having separate medical and dental commands. There is a single head of the dental directorate, a Navy captain, with a civilian VA deputy. Most of the dental services are provided at the United States ship (USS) Weeden Osborne Dental Clinic, a branch health clinic on the Navy base, because nearly 75 percent of the recruits require dental

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 107 work to become operationally ready for deployment (VA, 2010b). Of the 644,700 dental visits during the first year of the FHCC, 5,700 (less than 1 percent) were by veterans at the dental clinic on the west campus; the rest were at the east campus branch health clinics. Although the clinical staffs were not officially combined until October 1, 2010, the chief medical officers of the NCVAMC and the NHCGL were already fully engaged in merging the medical staffs, a goal that they strongly supported. The merger of inpatient services in 2006 had some active duty and VA clinicians working together in advance of moving all the active duty clinicians to the west campus (Interviews). The NCVAMC and the NHCGL executive committees of nursing services began meeting jointly in May 2010 (Fouse and Faber, 2011). Clinical Integration Acute Inpatient Mental Health Services The first major step toward creating an FHCC in North Chicago was to have the NCVAMC provide acute mental health services to DoD as well as to VA beneficiaries. The first DoD beneficiaries were admitted in October 2003 under a resource sharing agreement in which VA providers treated Navy mental health patients in the NCVAMC acute mental health inpatient unit and, in return, the Navy paid for the services and provided several psychiatric support staff. The NHGL was able to close its inpatient psychiatric unit and reduce overall staffing. The NCVAMC continued to provide acute inpatient mental health ser- vices to Navy recruits and to other DoD beneficiaries on a reimbursement basis until the Department of the Treasury (Treasury) fund for the FHCC became operational in 2011. The arrangement—for example, VA providers treating VA and DoD beneficiaries—continues, although it is now paid for seamlessly from the joint Treasury fund. Beginning in fiscal year (FY) 2013, a behind-the-scenes reconciliation process will allocate costs between the VA and the DoD in proportion to their respective workloads. Inpatient Medical, Surgical, and Pediatric Services The next step in the integration process was to centralize all inpatient medical and surgical services for adults and children at the NCVAMC. In this case, the range of services available to VA beneficiaries was expanded because the NCVAMC did not offer inpatient surgery, only some types of outpatient surgery. Previously, VA patients needing inpatient surgery had to be referred to other area VA facilities or to community hospitals. In ad- dition, VA and Navy inpatient beneficiaries benefit from the availability

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108 LOVELL FEDERAL HEALTH CARE CENTER MERGER of consultations with a broader range of specialists than would have been available if the Navy had built a separate hospital. In June 2006, after four existing operating rooms were renovated and four new operating rooms with recovery beds were constructed in a vacant ward, the NHGL closed its 22 inpatient beds and became the NHCGL (VA/DoD, 2007). Under a resource sharing agreement, DoD beneficiaries needing inpatient medical, surgical, or pediatric care were admitted to the NCVAMC (obstetrical cases are still referred to the community). VA nurses and technicians staffed and operated the nursing units, but Navy physicians who admitted patients could follow them and Navy surgeons could operate on veterans as well as on DoD beneficiaries. The NCVAMC was reimbursed as a TRICARE network provider. Because the NCVAMC was not an MTF, however, DoD beneficiaries were subject to copayments that they did not have to pay to receive services at the NHGL. Surgical services were essentially integrated before the FHCC came into being formally on October 1, 2010, but on that date a single line of authority, with a single head of the department of surgery under a single chief medical executive, was formally established. The funding arrangement also changed. All inpatient services—mental health, general medical, surgi- cal, and pediatric—are funded by the joint Treasury fund, and beginning in FY 2013, a reconciliation process will allocate costs between the VA and the DoD in proportion to their respective workloads. In addition, as part of the 5-year demonstration project, DoD beneficiaries are not being charged for copayments, just as if they were going to an MTF. The surgical services offered at the FHCC currently are general surgery, dermatology, otolaryngology, gynecology (women’s health), ophthalmology, orthopedics, podiatry, and urology (Lovell FHCC, 2012b). Physicians are both active duty servicemembers and VA civilians, and in many cases they treat both VA and DoD beneficiaries. Emergency and Urgent Care Services The NCVAMC emergency department (ED) was renovated and ex- panded from a 6-bed open floor plan to a 15-private-room configuration at the same time as the new surgical suites were constructed. In October 2006, all emergency services for DoD beneficiaries were transferred to the NCVAMC, and the NHGL (now the NHCGL), closed its ED. DoD ben- eficiaries benefited from having access to an ED staffed by board-certified emergency physicians in place of the internists who staffed the NHGL ED. Like DoD inpatients, they also had access to consultations from a greater range of specialties. VA beneficiaries benefited from having access to an ex- panded and more up-to-date ED, including privacy and gender-specific con- siderations for female patients. Originally, emergency/urgent care services

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 109 for DoD beneficiaries were reimbursed to the NCVAMC as a TRICARE network provider. Currently, services for both DoD and VA beneficiaries are paid for from the joint Treasury fund and the costs will be allocated between the departments through the reconciliation process. Women’s Health Clinic A new Women’s Health Center was built as part of the ambulatory care center (ACC). This clinic was designed to serve both women veterans and DoD beneficiaries. The center provides comprehensive primary care and gender-specific services in a separate, self-contained clinic space to provide an environment that is secure and supportive. Using Joint Incentive Fund (JIF) monies, the VA hired gynecology staff (replacing a lost Navy physi- cian billet); purchased digital mammography equipment and gender-specific equipment, such as a stereotactic biopsy device and a culposcopy unit; and hired two wellness/case management nurses. Without the combined veteran and military beneficiary populations, the VA would not have had the critical volume to support onsite mammography services or been able to maintain accreditation. Dental Services Tentative plans to combine the dental clinic for Navy staff at the NHGL (Building 200H) with the VA dental clinic on the west campus were abandoned when the square footage of the ACC was cut in half. Instead, the Navy dental clinic was moved to the Zachary and Elizabeth Fisher Medical and Dental Clinic on the east campus, which also provides medical care to active duty staff. There is no sharing of services, although the VA clinic does not have specialists such as endodontists and periodontists who are part of the staff at the USS Osborne. This is because the dentists at the USS Osborne are already booked to capacity to ensure that the recruits are ready for deployment. Ancillary Services In 2003, rather than renovate and expand its blood donor center to accommodate increasing volume, the NHGL agreed to renovate unused space in the NCVAMC for a new blood donor center. Renovating space in the NCVAMC saved $3 million in new construction costs. In lieu of paying for rent and utilities, the NHGL agreed to provide the NCVAMC approximately 415 units of blood products annually, worth approximately $47,000, or the equivalent of $14 per square foot (Harnly, 2005).

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110 LOVELL FEDERAL HEALTH CARE CENTER MERGER Other ancillary services, such as laboratory and radiology, were cen- tralized as part of the move into the ACC that began in December 2010. Outpatient Services After inpatient and emergency services were consolidated at the NCVAMC in 2006, the renamed NHCGL continued to provide outpatient services for DoD beneficiaries at the former hospital building until Decem- ber 2010, when the clinics were moved to the new ACC. Discussion Initially, the Navy was going to build the ACC for its beneficiaries and the VA was going to continue to provide outpatient services to veterans from its existing facilities (VA/DoD, 2002). Soon, however, the concept of integrating at least some outpatient services or clinics was adopted, in which both VA and DoD beneficiaries would be treated by either VA or Navy providers, depending on who was available. It was recognized that some services were unique to each department and should not be integrated. For example, the NCVAMC had long-term residential programs for veter- ans, such as the nursing home, the domiciliary, and residential rehabilitation treatment programs, which were not available to DoD beneficiaries. It was also agreed that the NCVAMC would staff and operate the inpatient mental health unit; the inpatient medical, surgical, and pediatric nursing units; and the ED. The Navy, for its part, had clinics in place on its base to medically process in and provide efficient health care for a large volume of enlisted recruits and students, and it did not make sense to move or to integrate them, except for ancillary services. It also did not make sense to create a joint pediatric clinic because the VA does not have pediatric beneficiaries. Prior to the integration of outpatient services in late 2010 and early 2011, the NHCGL offered 20 outpatient medical clinics in 200H and the NCVAMC offered 24 medical specialties and subspecialties (Table 4-1) that were candidates for clinical integration. Although the consistent vi- sion of local leaders was to unify clinical as well as administrative staff—to “allow a patient who could be a veteran, active duty servicemember, or family member to be treated by a Navy surgeon, a VA nurse, and a Navy technician” (DoD/VA, 2008)—pragmatic considerations dictated different degrees of staff and clinic integration in outpatient services. One factor was the reduced size of the ACC, which necessitated greater use of space in the VA hospital building (Interviews). Plans to integrate primary care services and dental clinics were changed because it no longer made sense to move or expand the existing VA primary care and dental clinics to serve both populations (Interviews). Instead, the Navy has a separate primary care

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 111 TABLE 4-1  Projected Fiscal Year 2011 Lovell Federal Health Care Center Full-Time-Equivalent Clinical Providers by Specialty (North Chicago Veterans Affairs Medical Center)/Clinic (Naval Health Clinic Great Lakes) Specialty/Clinic NCVAMC NHCGL Audiology 6.09 1.00 Cardiology 1.40 0.95 Dermatology 0.13 1.90 Endocrinology 1.97 Family Practice 6.00 Gastroenterology 3.63 General Surgery 2.11 2.90 Gynecology 1.05 2.00 Immunizations 1.00 Infectious Disease 0.23 Internal Medicine 19.15 5.95 Mental Health Clinic 49.01 11.00 Nephrology 0.70 Neurology 2.64 0.50 Occupational Therapy 0.98 Oncology 0.89 Ophthalmology 1.40 1.00 Optometry 1.88 1.00 Orthopedic 3.15 3.90 Otolaryngology 0.55 1.90 Outpatient Nutrition 2.00 Pediatric 3.89 Physical Therapy 5.95 8.00 Podiatry 1.43 2.00 Primary Care Employee Health 1.00 Pulmonary Disease 2.50 Rheumatology 1.00 Substance Abuse 3.00 Urology 1.10 0.90 Total 109.94 60.79 NOTE: This table pertains to the clinical personnel (e.g., physicians, psychologists, podiatrists, audiologists, nutritionists, and physical and occupational therapists) at the NHCGL’s 200H facility who moved to the ambulatory care center on the west campus, not the clinical person- nel in the branch health clinics who remained on the east campus (i.e., at Naval Station Great Lakes) or Veterans Administration personnel providing veteran-only services (e.g., long-term care, domiciliary care, and residential rehabilitation). It also does not include inpatient and emergency room providers. NCVAMC = North Chicago Veterans Affairs Medical Center; NHGL = Naval Hospital Great Lakes. SOURCE: Lovell FHCC, 2010b.

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112 LOVELL FEDERAL HEALTH CARE CENTER MERGER clinic in the new ACC building, and all dental services for DoD beneficia- ries remained on the east campus. Another factor was the provision in the executive agreement (EA) that VA providers can be seen by DoD providers, and vice versa, only if there is excess capacity. At the time of the integration of outpatient services, only dermatology and otolaryngology had excess capacity and were fully integrated in terms of staff and patients for regular scheduling purposes; other clinical services were shared on an ad hoc basis when there were openings. The plan that evolved and was eventually implemented resulted in a va- riety of organizational arrangements for outpatient services. As mentioned already, some of the health delivery sites on the Navy base continued to do what they did before, the main difference being that the Navy civilians working there became VA employees and administrative and some clinical support services (e.g., laboratory) were centralized. These branch health clinics include the USS Red Rover, which screens recruits for medical and dental problems as they arrive and provides immunizations, eyeglasses, and women’s health services; the USS Weeden Osborne, which provides dental services to recruits, a large percentage of whom have dental deficiencies; the USS Tranquility, which provides medical services to recruits and active duty members of the Recruit Training Command (RTC) staff; and the Fisher Clinic, which provides primary medical and dental care to the active duty staff at the Naval Station Great Lakes (NSGL). As already noted, the primary care clinics remain separate and are staffed separately by DoD and VA providers. In the DoD primary care clinic (and the pediatric clinic), DoD providers treat DoD beneficiaries and use the Armed Forces Health Longitudinal Technology Application (AHLTA) to document visits while VA providers treat veterans and use the Veterans Health Information Systems and Technology Architecture (VistA). Having the DoD primary care clinic use AHLTA ensured that information affect- ing deployability, such as immunizations, would be available immediately, especially if the interoperability solutions under development were not operational when the FHCC became operational. The existing VA primary care clinic was little affected because providers did not need to access or document information in AHLTA except for dual eligible retirees. DoD pro- viders treating dual eligible beneficiaries could view their VA health records through the Bi-directional Health Information Exchange, although this is a time-consuming process and is not always done (Interviews). The women’s clinic has both DoD and VA providers, but DoD pro- viders treat DoD beneficiaries and use AHLTA while VA providers treat veterans and use VistA. The women’s clinic is integrated in another way, however, because it also provides primary care and onsite radiology. In addition to space considerations, the different policies concerning outpatient scheduling and standards of the VA and the Bureau of Medicine

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 113 and Surgery (BUMED) also support having separate primary care clinics. For example, the VA requires an appointment within 7 days, and BUMED requires one within 14 days. Many VA clinicians were part-time (see Table 4-1) at the NCVAMC, available only several times a week. The Navy had a full-time gynecologist, orthopedist, otolaryngologist, dermatologist, and urologist. Although only dermatology and otolaryngology are formally integrated, DoD beneficia- ries are seen by VA specialty providers and vice versa on a space-available basis. DoD beneficiaries therefore benefit from access to VA providers with specialties not present among Navy providers, including pulmonary critical care, infectious diseases, gastroenterology, nephrology, endocrinol- ogy, rheumatology, and hematology/oncology (Table 4-1). Veterans benefit from the access provided by the expanded clinical staffing. Navy inpatients and ED users also benefit from access to consultations from VA specialists (Interviews). The pharmacy was designed to be integrated, where the DoD and the VA pharmacists could fill prescriptions for both TRICARE enrollees and veterans. This arrangement was dependent on an orders portability solu- tion for pharmacy, which was not ready for use when the ACC opened and will not be ready until FY 2014, at the earliest. Instead, DoD pharmacists mostly serve TRICARE beneficiaries, using the DoD’s AHLTA, while the VA pharmacists mostly serve veterans, using the VA’s VistA. Similarly, the efficiency of combining specialty clinics in the ACC on the west campus has been reduced by lack of interoperability between the two EHR systems. The plan was for clinical notes and information about labo- ratory tests, radiology, and prescriptions for recruits and other TRICARE enrollees seen in the ED and specialty clinics to be entered into VistA and for the information to be automatically populated in AHLTA. Quick, if not instant, entry into AHLTA is required because active duty servicemembers may be transferred on short notice and must take complete medical records with them. The information also might affect whether they are considered to be medically ready to be deployed. These capabilities were not ready for use when the ACC opened, necessitating the use of manual workarounds to duplicate the information entered into VistA into AHLTA, which has significantly affected productivity because of the increased paperwork load. Conclusions Concerning Degree of Integration The final organization of the FHCC displays various degrees of inte- gration across services (see Table 4-2). Some services are VA only, such as long-term care and domiciliary, which only veterans can receive. Some are Navy only, such as the branch health clinics on the east campus that serve only active duty servicemembers. Inpatient mental health, medicine,

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134 LOVELL FEDERAL HEALTH CARE CENTER MERGER 70 60 Patient Satisfaction Score 50 40 FHCC Actual Score 30 FHCC Benchmark VHA Average Score 20 10 0 FY 2009 FY 2010 FY 2011 FIGURE 4-11  Department of Veterans Affairs outpatient satisfaction scores, fiscal years 2009–2011. NOTE: The VA changed the scoring methodology in 2009, making results for 2008 and earlier noncomparable. SOURCES: Lovell FHCC and VA, 2011. Figure 4-11, color 70 60 Patient Satisfaction Score 50 40 FHCC Actual Score 30 FHCC Benchmark VHA Average Score 20 10 0 FY 2009 FY 2010 FY 2011 FIGURE 4-12  Department of Veterans Affairs inpatient satisfaction scores, fiscal years 2009–2011. NOTE: The VA changed the scoring methodology in 2009, making results for 2008 and earlier noncomparable. SOURCE: Lovell FHCC and color Figure 4-12, VA, 2011.

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 135 TABLE 4-3  Department of Defense Patient Satisfaction Scale for the Lovell Federal Health Care Center Score Basis 5 (Excellent) More than 5 percent above the BUMED average 4 (Very Good) Between 5 percent above and below the BUMED average 3 (Good) Between 5 and 10 percent below the BUMED average 2 (Fair) Between 10 and 16 percent below the BUMED average 1 (Poor) 16 percent or more below the BUMED average SOURCE: Lovell FHCC, 2010c. it is more than 5 percent above the BUMED average, it gets 5 points, which is considered to be “excellent” (Table 4-3). The similar score is derived from the VA surveys except that the com- parison is the overall average for VISN 12 and the intervals are different (Table 4-4). The benchmark considered successful is a score of 4 or higher. Both DoD and VA patient satisfaction scores were 4s (very good) on the eve of full integration in October 2010. The measure of VA patient sat- isfaction was lower than the benchmark (a score of at least 4) in the early months of the integration effort and again in the summer of 2011, but the measure jumped to excellent (5) and stayed there at the beginning of the second year. The measure of DoD patient satisfaction has alternated be- tween good (3) and very good (4) during the same initial 16-month period (Figure 4-13). These trends indicate that both sets of beneficiaries have been less satisfied than they were before the Lovell FHCC took over operations, although VA beneficiaries have been much happier recently. TABLE 4-4  Veterans Administration Patient Satisfaction Scale for the Lovell Federal Health Care Center Score Basis 5 (Excellent) More than 5 percent above the VISN average 4 (Very Good) Between 0 and 5 percent above the VISN average 3 (Good) Between 0 and 5 percent below the VISN average 2 (Fair) Between 5 and 10 percent below the VISN average 1 (Poor) 10 percent or more below the VISN average SOURCE: Lovell FHCC, 2010c.

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136 LOVELL FEDERAL HEALTH CARE CENTER MERGER 6 Patient Satisfaction Score 5 4 3 2 VA DoD 1 0 1 1 1 11 e 11 11 11 11 0 11 11 11 11 12 0 0 /1 /1 /1 in /1 /1 /1 9/ 2/ 8/ 12 1/ 3/ 4/ 5/ 6/ 7/ 1/ l 10 11 12 10 se 11 Ba FIGURE 4-13 Lovell Federal Health Care Center patient satisfaction scores, O ­ ctober 2010–June 2012. SOURCE: Lovell FHCC. Figure 4-13, colo Provider Satisfaction/Morale The FHCC is subject to an annual organizational climate survey by the Defense Equal Opportunity Management Institute which asks questions in two areas: equal employment opportunity climate and organizational ef- fectiveness. The latest survey was conducted in January 2012. The response rate was a little more than 40 percent for both civilian and active duty responders and also proportional across pay grades/ranks. The respondents were asked to rate their job satisfaction, their trust in the FHCC, the cohesion and the effectiveness of their work group, and their perception of the cohesion of the FHCC leadership on a 5-point scale, in which a higher number means greater satisfaction, trust, commitment, and cohesion. The results show that the ratings by FHCC personnel in January 2012 were generally comparable to those by all Navy, all DoD, and all federal civilian personnel (Figure 4-14). The average ratings by FHCC personnel in 2012 were also comparable to the ratings done in 2011, essentially bracketing the first year of the FHCC (Figure 4-15). Mission Readiness of Navy Staff, Recruits, and “A” School Students The impact of the FHCC integration on the operational readiness of active duty personnel was of paramount concern to the Navy. Great Lakes is the only enlisted boot camp in the Navy and the location of many of the

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 137 Job Satisfaction Leadership Cohesion FHCC Work Group Cohesion Navy Work Group Effectiveness DoD All Federal Trust in Organization Organizational Commitment 0 1 2 3 4 5 Staff Workplace Effectiveness Score FIGURE 4-14 Average ratings of organizational effectiveness of their workplace by active duty and civilian staff at the Lovell Federal Health Care Center, all Navy facilities, all Department of Defense facilities, and all federal civilian workplaces in 2012. NOTE: Respondents to an annual survey of the organizational climate at federal facilities administered by the Defense Equal Opportunity Management Institute were asked to give their4-14, color of certain organizational features on a 5-point Figure perception scale rate in which a higher number is better; e.g., a 4 means greater job satisfac- tion than a 3. DoD = Department of Defense; FHCC = Federal Health Care Center. SOURCE: Lovell FHCC, 2012a. Job Satisfaction Leadership Cohesion Work Group Cohesion 2012 Work Group Effectiveness 2011 Trust in Organization Organizational Commitment 0 1 2 3 4 5 Staff Workplace Effectiveness Score FIGURE 4-15  Average ratings of organizational effectiveness of the Lovell Federal Health Care Center by its active duty and civilian staff in 2011 and 2012. NOTE: Respondents to an annual survey of the organizational climate at the Lovell Federal Health Care Center administered by the Defense Equal Opportunity Management Figure 4-15, color to give their perception of certain organizational Institute were asked features on a 5-point scale rate in which a higher number is better; e.g., a 4 means greater job satisfaction than a 3. SOURCE: Lovell FHCC, 2012a.

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138 LOVELL FEDERAL HEALTH CARE CENTER MERGER Navy’s advanced training schools; therefore, a slowdown of training would negatively affect the entire Navy. On the other hand, having sailors with untreated health problems while on an extended cruise is also disruptive. This issue was mostly dealt with by keeping the recruit medical processing operation and the recruit and student health and dental clinics in place on the base, and not trying to move and integrate them with the rest of the FHCC’s patient care and patient services. However, some services for Navy personnel, including recruits and students, were moved and integrated (e.g., specialty care; emergency care; acute inpatient psychiatry, surgery, and general medicine; women’s health; and laboratory and pharmacy services). Administrative services such as purchasing of supplies and computer system support for the Navy branch health clinics were also centralized. The Navy agreed on three measures of military medical readiness that collectively are being tracked as one of the 15 measures of integration suc- cess. They are the following: • keeping recruits in temporary holding units for medical reasons after they graduate under 5 percent, • keeping students not under instruction for medical reasons less than 2 percent, and • keeping the medically indeterminate status of active duty staff un- der 5 percent. Recruits in Temporary Holding Units for Medical Reasons After They Graduate Enlisted recruits who graduate from boot camp but are medically un- able to transfer are assigned to temporary holding units. It is the responsi- bility of the MTF, in this case the Lovell FHCC, to provide the care needed to keep this rate as low as possible. According to the FHCC’s scorecard, Lovell has scored mostly 5s since it was launched in October 2010, meaning that the rate has been 2 percent or less (Lovell FHCC, 2010c). However, the rate jumped to more than 6 percent in January 2011 and also experienced a lesser increase (to less than 5 percent) in August and September 2011. Enlisted Students Not Under Instruction for Medical Reasons The percentage of enlisted students unable to attend training for medi- cal reasons fell by half, to less than 1 percent, in September and October 2010 and, except for 1-week spikes in January 2011 and January 2012, it has trended downward to about 0.5 percent (Figure 4-16).

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 139 3.0 Percentage of Enlisted Students 2.5 2.0 1.5 Benchmark Rate Actual Rate 1.0 0.5 0.0 20 1 11 11 10 /6 10 11 9 0 5/ 11 7/ 11 1/ 201 12 10 10 10 3/ 11 00 01 12 20 20 20 20 20 20 20 20 20 20 20 /2 /2 / /6 6/ 6/ 6/ 6/ 6/ 6/ 6/ 6/ 6/ 6/ 6/ /6 6/ 9/ 3/ 9/ 3/ 7/ 1/ 5/ 1/ 11 11 FIGURE 4-16 Percentage of enlisted students not under instruction for medical reasons, November 2009–April 2012. NOTE: A lower score is better. SOURCE: Lovell FHCC. Figure 4-16, color Medically Indeterminate Status An active duty servicemember can be fully medically ready, partially medically ready, or not medically ready, or his or her medical readiness can be indeterminate. To be fully medically ready, servicemembers have to meet a list of requirements. Those who are ill or pregnant or who have acute dental problems are considered not medically ready. Those who are lacking some tests or immunizations are partially ready. Finally, those with overdue periodic health assessments, overdue periodic mental examinations, or lost medical records are classified as medically indeterminate. In December 2010, 82 percent of active duty personnel at Great Lakes were medically ready for deployment, 4 percent were partially ready, 10 percent were not ready, and the status of 4 percent was medically indeter- minate (FHCC communication). This was much better than the U.S. Armed Forces as a whole. In December 2010, the equivalent numbers were 67, 8, 13, and 12 percent, respectively (Woodson, 2011). However, Great Lakes is the Navy’s major training center where most servicemembers are relatively healthy young recruits and students, and the expectations for operational medical readiness are high. The Navy chose to track the percentage of medically indeterminate ac- tive duty servicemembers, those whose status is unknown, as its measure of active duty individual medical readiness. In addition, an MTF’s percentage

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140 LOVELL FEDERAL HEALTH CARE CENTER MERGER of personnel whose individual medical readiness status is indeterminate is a factor in the Navy’s performance-based budgeting formula for MTFs. During September 2010, the medical readiness indeterminate rate was between 4 and 5 percent. From October 2010 through January 2012, the scorecard score was 4 for most months, which means it was between 2.5 and 5 percent. It was a 5 in October 2010 and in January and June 2011, meaning it was 2.5 percent or less. Findings and Conclusions Concerning Military Operational Readiness The data presented on military medical readiness are consistent with the statement the RTC commander made to the committee at its third meet- ing. He said that the establishment of the FHCC has not had a noticeable effect on the rate of recruits who are able to graduate on time and transfer to their next assignments, some to additional training and some to imme- diate duty on ships. He said that when an issue does arise, it is addressed immediately and satisfactorily by the FHCC leadership. An early example was when a recruit was released from the inpatient psychiatric ward with- out notice to the RTC. The FHCC immediately worked out a procedure with the RTC to prevent such a reoccurrence. Several interviewees indicated that maintaining operational readiness involved more effort than was previously necessary. They reported that it takes more time to keep medical records up to date because the DoD and the VA EHR systems do not interface and, therefore, the documentation of specialty, inpatient, and emergency services provided on the west campus must be manually entered into AHLTA. IT and laboratory services are provided centrally rather than locally, which is more cost effecive overall but can reduce responsiveness to branch health clinics’ needs. Although the two campuses are only 1.5 miles apart, it takes 20–30 minutes each way to travel from one campus to the other because the roads are not direct and the naval base can be accessed only through a few secure gates. Unless the base ambulance service is used in an emergency, the transportation is often provided by hospital corpsmen, which reduces their availability in the clinic. Training and Research The creation of the FHCC has generated opportunities for improved training and research that are not yet exploited but are in the plans of the Lovell FHCC and its affiliated medical school, the Rosalind Franklin University of Medicine and Science. These were discussed in the presenta- tions to the committee at its September 2011 meeting in North Chicago and in an earlier site visit to the university by the committee staff. Those

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 141 discussions centered on several features of the combined FHCC, including the opportunities that the larger and more diverse patient population and the broader range of clinical services offer for both teaching and research. Rosalind Franklin has been affiliated with the NCVAMC since 1980, when the university moved from downtown Chicago to North Chicago. The university has many doctoral and masters degree programs requiring clinical experience that is provided in part by the FHCC. There are schools of medicine, podiatry, pharmacy, and health professions, and a school of basic science that grants doctorates in the biomedical sciences. About 45 medical students a year have third-year clerkships in psychiatry, internal medicine, and neurology. There are about 40 residents a year in psychiatry and general internal medicine and 10 fellowships in endocrinology, pulmon- ology, infectious diseases, and cardiology. The 140 residents in podiatry do rotations at the FHCC, as well as 7 psychology students, 7 physical therapy students, 2 nurse anesthesiology students, and 18 students from other programs. The university has started a school of pharmacy, and there are plans for the 12 initial pharmacy students to rotate at the FHCC pharmacy. The FHCC also has affiliations with Loyola University Chicago and the University of Illinois, and each year provides training for more than 400 residents, interns, and medical students, as well as students of other disciplines, including health services administration, audiology/speech pa- thology, biomedical engineering, dental assisting, medical technology, phar- macy, nursing, physical therapy, podiatry, psychology, and social work. Training Opportunities In their presentation to the committee, the director and deputy director of the FHCC said it has added new clinical disciplines for training experi- ence, for example, family medicine, pediatrics, and hospitalist practice, as well as increased faculty and medicine. Trainees can now also be exposed to other disciplines, such as dermatology, ophthalmology, gynecology, and emergency medicine. There are more ambulatory care preceptors. The FHCC will also be able to increase the pool of speakers and the diversity of topics for grand rounds and multidisciplinary conferences. Rosalind Franklin will be able to make greater use of the FHCC as one of its training institutions because of the expanded number of specialties and subspecialties offered there. Many VA providers have faculty appoint- ments, and the university has now appointed Navy clinicians as faculty. Research Opportunities According to the integration performance benchmark, the amount of research funding at the Lovell FHCC is larger than it was leading up to

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142 LOVELL FEDERAL HEALTH CARE CENTER MERGER October 1, 2010. The leaderships of both Rosalind Franklin and the FHCC see the greater diversity of the patient population, now including women and children and the entire age range, as new research opportunities. The expansion of clinical staff increases the number of potential researchers. Both institutions also mentioned having access to DoD research fund- ing as well as to VA research funding. Although a VA clinician has had a major research program at the university on battlefield critical care, funded by the DoD, the FHCC and the university are not currently collaborating on clinical trials, although the NCVAMC and the university have in the past. REFERENCES DoD/VA (Department of Defense/Department of Veterans Affairs). 2008. Good News [news- letter]. February. http://www.tricare.mil/DVPCO/downloads/DoD-VA-Good-News- Feb-2008.pdf (accessed September 7, 2012). DoD/VA. 2010. Executive agreement for the Department of Defense-Department of Veterans Affairs Medical Facility Demonstration Project, Federal Health Care Center. April 23. http://tricare.mil/tma/congressionalinformation/downloads/2010310/111-288%20 Section%201701(d)(1)%20FHCC%20EA.pdf (accessed September 6, 2012). Fouse, S., and B. Faber. 2011. Patient Services Directorate. Presentation to the IOM Commit- tee on Evaluation of the Lovell Federal Health Care Center Merger by Dr. Sarah Fouse and CDR Bridgette Faber, associate director and assistant director, Patient Services Di- rectorate, Lovell FHCC, North Chicago, IL, June 29. GAO (U.S. Government Accountability Office). 2012. VA/DoD health care: Costly informa- tion technology delays continue and evaluation plan lacking. GAO-12-669. Washington, DC: GAO. http://www.gao.gov/assets/600/591895.pdf (accessed September 7, 2012). Harnly, M. J. 2005. A qualitative analysis of resource sharing agreements between Naval Hos- pital Great Lakes and North Chicago Veterans Affairs Medical Center: The iron triangle theory of healthcare integration. Master’s Thesis, Army-Baylor Program in Healthcare Administration, Fort Sam Houston, TX. http://www.dtic.mil/dtic/tr/fulltext/u2/a443921. pdf (accessed September 13, 2012). Joint Commission. 2011. Improving America’s hospitals—The Joint Commission’s annual report on quality and safety 2011. http://www.jointcommission.org/2011_annual_report/ (accessed September 21, 2012). Lovell FHCC (Captain James A. Lovell Federal Health Care Center). 2010a. Concept of opera- tions. October 1. Provided by the Lovell FHCC. Lovell FHCC. 2010b. Interim business plan for fiscal year 2011. Provided by the Lovell FHCC. Lovell FHCC. 2010c. FHCC integrated benchmarks: Tech manual. Provided by the Lovell FHCC. Lovell FHCC. 2012a. Organizational climate survey synopsis. January. Provided by the Lovell FHCC. Lovell FHCC. 2012b. Business plan for fiscal year 2013 through 2015. Provided by the Lovell FHCC. Shortell, S. M., R. R. Gillies, D. A. Anderson, K. M. Erickson, and J. B. Mitchell. 2000. Re- making health care in America: The evolution of organized delivery systems, 2nd Edition. San Francisco: Jossey-Bass.

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INITIAL RESULTS OF THE INTEGRATION DEMONSTRATION 143 VA. 2010a. Communications Department working side-by-side. The Great Lakes News (VISN 12 Newsletter), January. http://www.visn12.va.gov/docs/gln/Great_Lakes_ News_2010_01.pdf (accessed September 7, 2012). VA. 2010b. USS Osborne remains critical component in recruit dental readiness. The Great Lakes News (VISN 12 Newsletter), October. http://www.visn12.va.gov/docs/gln/Great_ Lakes_News_2010_10.pdf (accessed September 7, 2012). VA. 2011. FY 2011 performance and accountability report. November. http://www.va.gov/ budget/report/ (accessed September 13, 2012). VA/DoD. 2002. The Department of Veterans Affairs and the Department of Defense report on health care resource sharing, FY 2002. March 23. http://tricare.mil/tma/congressional information/downloads/DoD%20VA%20Sharing%20signed%20Mar%2027%202003. pdf (accessed September 16, 2012). VA/DoD. 2007. FY 2006 VA/DoD Joint Executive Council annual report. February. http:// www.tricare.mil/DVPCO/downloads/VADoD2006.pdf (accessed June 8, 2012). Woodson, J. 2011. Prepared statement by Jonathan Woodson, MD, Assistant Secretary of Defense (Health Affairs), regarding the Military Health System, overview before the Sen- ate Armed Services Committee Personnel Subcommittee, May 4. http://armed-services. senate.gov/statemnt/2011/05%20May/Woodson%2005-04-11.pdf (accessed September 7, 2012).

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